What are the recommended medications for managing angina?

Recommended Medications for Managing Angina

Beta-blockers and/or calcium channel blockers (CCBs) are recommended as first-line treatment for most patients with chronic angina, with short-acting nitrates for immediate symptom relief. 1

First-Line Medications

Short-Acting Nitrates

• Recommended for immediate relief of acute angina symptoms 1
• Should be taken as needed in response to pain and prophylactically before engaging in activities that trigger angina 1
• Sublingual glyceryl trinitrate (nitroglycerin) is the standard formulation
• Buccal preparations can be considered if patients don't respond to sublingual forms 1

Beta-Blockers

• First-line therapy for most patients with chronic coronary syndrome (CCS) 1
• Particularly beneficial for patients with:
  • Prior myocardial infarction
  • Heart failure with reduced ejection fraction
  • Hypertension
  • Tachyarrhythmias 1
  • High heart rate 2
• Common options include:
  • Metoprolol: 50-200 mg twice daily
  • Atenolol: 50-200 mg per day
  • Bisoprolol: 10 mg per day
  • Carvedilol: 6.25-25 mg twice daily 1
• Caution: Avoid in patients with sick sinus syndrome, AV conduction disorders, severe bradycardia, or hypotension 1

Calcium Channel Blockers (CCBs)

• First-line alternative when beta-blockers are contraindicated or not tolerated 1
• Dihydropyridine CCBs (e.g., amlodipine) are preferred when combined with beta-blockers 3
• Amlodipine has demonstrated effectiveness in exercise-induced angina at 5-10 mg/day 4
• Non-dihydropyridine CCBs (verapamil, diltiazem) should not be combined with ivabradine 1
• Caution: Use with care in heart failure with reduced ejection fraction 1

Second-Line and Combination Therapy

If symptoms are not adequately controlled with initial therapy:

1. Combination of beta-blocker and dihydropyridine CCB should be considered first 1

2. If further treatment is needed, add one of:

   • Long-acting nitrates:

     • Should be administered with a nitrate-free interval to avoid tolerance 1
     • Minimum effective patch dose is 10 mg 1

   • Ranolazine:

     • Effective for chronic stable angina as add-on therapy 5
     • Particularly useful in patients with low heart rate and/or blood pressure 1

   • Nicorandil:

     • Recommended as add-on therapy when symptoms are inadequately controlled 1
     • Particularly useful for patients with coronary artery spasm 1

   • Trimetazidine:

     • Can be considered for patients with microvascular angina 1
     • Useful when heart rate or blood pressure is low 1

   • Ivabradine:

     • Consider in patients with beta-blocker intolerance 1
     • Contraindicated with non-dihydropyridine CCBs 1

Treatment Algorithm

1. Start with short-acting nitrates for immediate symptom relief 1

2. Initial regular treatment:

   • Beta-blocker OR
   • CCB (if beta-blocker contraindicated or not tolerated)
   • Selection based on comorbidities, heart rate, blood pressure, and tolerance

3. If inadequate control with monotherapy:

   • Add dihydropyridine CCB to beta-blocker OR
   • Switch to another class if monotherapy causes side effects 6

4. If dual therapy is insufficient:

   • Add long-acting nitrate, ranolazine, nicorandil, or trimetazidine
   • Consider patient's hemodynamic profile and comorbidities

Additional Important Considerations

• Aspirin: All patients should receive aspirin 75-162 mg daily unless contraindicated 1
• Lipid management: All patients should have cholesterol measured and treated according to guidelines 1
• Blood pressure control: Essential component of management 1
• Smoking cessation: All patients who smoke should be advised to stop 1

Common Pitfalls to Avoid

1. Using non-dihydropyridine CCBs with beta-blockers can cause excessive bradycardia 3
2. Nitrate tolerance develops with continuous use - ensure nitrate-free intervals 1
3. Combining ivabradine with verapamil or diltiazem is contraindicated 1
4. Using nitrates in patients taking phosphodiesterase inhibitors is contraindicated 1
5. Triple therapy may not be more effective than optimized dual therapy and may increase side effects 6

Remember that medication selection should prioritize the patient's comorbidities, hemodynamic status, and tolerance to optimize both symptom control and long-term outcomes.